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Fig.23.1Hypothyroidismmanagementalgorithm.TPOAb,thyroidperoxidaseantibodies.
Patienteducation
Lifelong levothyroxine replacement is usually needed—patients should be counselled
accordingly.
Provide written information wherepossibleand/ordirect patientsto reputableonline
sourcestoresearchfurther.
Lifestyleandsimpleinterventions
Caffeineimpairslevothyroxineabsorptionandshouldbeavoided60minutesbeforeand
aftertakingthemedication.
Smokinghasbeenshowntoimpairthyroidglandfunction;smokingcessationmaybe
beneficial.
Pharmacologicalmanagement
Levothyroxine(T4)replacementforprimaryhypothyroidismissimple,safe,andeffective
forthemajorityofpatients(seeFig.23.1).
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Levothyroxineshouldbetakenonanemptystomachideallyanhourbeforeeating;this
isusuallyfirstthinginthemorningbutitcanbetakenatnight.
Excess levothyroxine replacement can cause symptoms of thyrotoxicosis, AF, and
osteoporosis.
Liothyronine(T3)treatmentisnotusedroutinely—seeBox23.1forfurtherdetails.
Box23.1Liothyronine(T3)treatment
ThereiscurrentlynoevidencesupportingtheuseofLiothyronine(T3)replacementor
natural thyroid extracts. An endocrinologist may consider T3 replacement if
levothyroxinetherapydoesnotresolvesymptomsdespitenormalizationofTFT.
For patientsalreadyestablished on T3therapy, consider switching to levothyroxine
followingdiscussionwiththepatient.Adviceshouldbesoughtfromanendocrinologist
onhowtodothissafely.
Source:datafromNICENG145andUKGuidelinesfortheUseofThyroidFunctionTests.July2006.
BritishThyroidAssociation.
Psychosocialconsiderations
Low mood/depression are common, but these may improve with adequate thyroid
hormone replacement. Data suggest 5–10% of patients may have persistent symptoms
despitetreatment.
Complications
If left untreated, hypothyroidism can lead to cardiac failure and dementia, and can
significantlyimpairqualityoflifeduetoongoingsymptoms.
Rarely,untreatedhypothyroidismcanleadtomyxoedemacoma—amedicalemergency
characterized by hypothermia, hypoglycaemia, bradycardia, cardiac failure, cyanosis,
seizures,andimpairedconsciousness.
After commencing levothyroxine or changing the dose, repeat testing should notoccur for a
minimum of 2 months as stable thyroid hormone levels will nothave beenachieved before
this.
Monitoringandfollow-up
TFT should be checked annually once the patient is established on a stable dose of
levothyroxine—TSHmonitoringinisolationisusuallysufficient.
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Patients who continue to experience symptoms despite adequate levothyroxine
replacementshouldbeinvestigatedforalternativecauses.
Wherethediagnosisofhypothyroidismisindoubt,levothyroxinecanbestoppedand
TFTrechecked6weekslater.
Where alternative causes cannot be identified and symptoms persist, endocrinology
referralmaybewarrantedinordertoreviewongoingmanagement.
Specialconsiderations
Pregnancy
Pregnancyincreasesthyroidhormonerequirements;doseincreasesof25–50%areusually
neededfromthefirsttrimester.
Womenwithknownhypothyroidismwhoareplanningpregnancyshouldbereferredto
aspecialistandhaveTFTcheckedpriortoconception.Theyshouldbeadvisedtodelay
conceptionifnoteuthyroid.
If already pregnant, TFT should be checked immediately and a specialist’s advice
soughtregardinglevothyroxinedoseadjustment.
TFTshouldbecheckedevery6weeksduringpregnancytoensurethepatientremains
euthyroid,minimizingtheriskofobstetricandneonatalcomplications.
Furtherreading
1. BMJ Best Practice (2021). Primary hypothyroidism. Available at:
www.bestpractice.bmj.com/topics/en-gb/535
2.WassJ,OwenK(eds)(2014).Thyroid.In:OxfordHandbookofEndocrinologyandDiabetes,3rded
(pp. 1–105). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199644438.003.0001
3. Wilkinson IB, Raine T, Wiles K, et al. (2017). Endocrinology. In: Oxford Handbook of Clinical
Medicine, 10th ed (pp. 202–41). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199689903.003.0005
4.AllahabadiaA,RazviS,AbrahamP,etal.(2009).Diagnosisandtreatmentofprimaryhypothyroidism.
BMJ.338:b725.
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Chapter24
Osteoporosis
Guidelines: NICE CG146 (Osteoporosis: assessing the risk of fragility
fracture):https://www.nice.org.uk/guidance/cg146
NationalOsteoporosis GuidelineGroup(NOGG2021:clinicalguidelinefor
thepreventionandtreatmentofosteoporosis):https://www.nogg.org.uk/full-
guideline
Endocrine Society (Pharmacological management of osteoporosis in
postmenopausal women): https://www.endocrine.org/clinical-practice-
guidelines/osteoporosis-in-postmenopausal-women
OUPdisclaimer:OxfordUniversity Press makesno representation, express
or implied, that the drugdosagesarecorrectand thatthe recommendations
are an exclusive or mandatory course of care. All health professionals
readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake
theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Osteoporosis is a systemic skeletal disease, characterized by low bone mass and
microarchitecturaldeterioration ofbonetissue,leadingto↑bone fragilityand↑fracture
risk1. Osteoporosis leads to >300,000 fragility fractures in the UK each year. These
fractures occur from low-impact trauma, such as a fall from standing height. The
prevalence of osteoporosis is 2% at age 50, and 25% at age 80 in women. There is a
significantassociatedcost,mostlyrelatedtohipfracturecare.
Diagnosis
History/diagnosticcriteria
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Fragility fractures result from a mechanical force that would not ordinarily result in
fracture. They are associated with low bone mineral density (BMD) and occur most
commonly in the vertebrae, proximal femur, and distal radius (also consider in the
humerus, pelvis, and ribs). Hip and vertebralfractures are associated with reduced life
expectancy.
AssessmentcriteriaandriskfactorsforosteoporosisaresummarizedinTable24.1.
Table24.1Assessmentcriteriaandriskfactorsforosteoporosis
Age
category
Assessif
Women
≥65
years
Men≥75
years
Allshouldbeassessed
Women
50–64
years
Men50–
74years
Historyoffragilityfracture
Historyoffalls
Familyhistoryofhipfracture
Currentorrecentfrequentuseofsteroids(≥7.5mgprednisolone/dayfor≥3monthsorequivalent)
BMI<18.5kg/m
2
Smoker
Alcoholintake>14units/week
Secondary causes of osteoporosis, e.g. hypogonadism, untreated premature menopause,
hyperthyroidism, hyperparathyroidism, diabetes, inflammatory bowel disease (IBD), rheumatoid
arthritis,COPD,chronicliverfailure,CKD
Source:datafromNICECG146.
The patient groups listed in Table 24.1 should be assessed initially using a risk
assessmenttool(see‘Methodsofriskassessment’).
However, the following two groups should be referred for a DXA scan directly,
withoutusingariskassessmenttool:
Patientsaged>50yearsANDapreviousfragilityfracture
Patientsaged<40 years ANDcurrent/recent high-dose steroid usefor ≥3 months (equivalentto
≥7.5mgprednisoloneOD)ORpreviousfragilityfracture.
Methodsofriskassessment
Two risk assessment tools, FRAX® and QFracture®, are available for use in the UKto
estimatethe10-yearprobability(asapercentage)ofamajorosteoporoticorhipfracture.
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BothtoolsaredesignedtobeusedbeforeDXAscanningandhelptodecideifaDXA
scan is necessary(aside from the exceptions previouslymentioned). Onceapatienthas
hadaDXAscan,theFRAX®scoreshouldberecalculatedincorporatingtheDXAresult.
FRAX
®
FRAX2can be usedforpeopleaged40–90years, eitherwithor withoutBMDvalues. It
takesintoaccountpreviousandfamilyhistoryoffractures,smoking,alcoholandsteroid
use,andriskfactorsfor secondaryosteoporosis.Theresultisplottedontoagraph(Fig.
24.1)providedbytheNationalOsteoporosisGuideline Group(NOGG) whichplotsage
againstrisk,andindicateswhetherthepatientwouldbenefitfromtreatmentornot.
Fig.24.1Graphshowingthe10-yearprobability(%)ofapatienthavingamajor(spine,hip,forearm,or
humerus)osteoporoticfracture.Thedottedlinerepresentstheinterventionthresholdbasedonthe10-year
probabilityof ahip fracture. Patientsinthe lightestbluezonecanbe reassured.Patientsinthe darkest
bluezone should be treated.Patients in the mid blue zone may be referred for BMD measurementsin
order to reassess their fracture probability, or may be directed to treatment if above the dotted line,
dependingonclinicaljudgement.
ReproducedunderaCreativeCommonsAttribution4.0International(CCBY4.0)fromCompston,J.et
al.(2017).UKclinicalguidelineforthepreventionandtreatmentofosteoporosis.ArchOsteoporos12,
43.
QFracture
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QFracture3canbeusedforpeopleaged30–99years.BMDvaluescannotbeincorporated
into the algorithm. QFracture® considers more specific comorbidities such as chronic
liverdiseaseanddementiacomparedtoFRAX®.
If treatmentisadvisedafterusingtheriskassessmenttools,thepatientshould havea
DXAscanpriortocommencingtreatment.
Patientsabovetheupperagelimitsdefinedbythetoolsareautomaticallyconsideredtobeat
high risk.Rememberthatinpatients>80years, resultsshouldbeinterpretedcautiouslyas a
10-yearscoremayunderestimatetheirshort-termrisk.
Investigations
Bloods
FBC
U&E(CKD)
CRP/ESR(chronicinflammatorydisease)
Calcium(hyper)
LFT(chronicliverdisease)
TFT(hyperthyroidism).
Considertestingifclinicalsuspicion:
Serum25-hydroxyvitaminD(vitaminDdeficiency)
Myelomascreen
PTH(hyperparathyroidism)
Pituitaryhormones(androgendeficiencyinmales,prematuremenopauseinfemales,prolactinoma
inbothsexes)
TestsforCushing’ssyndrome
Endomysial/tissuetransglutaminaseantibody(coeliacdisease).
Imaging
DXAscan
DXAusesX-raystonon-invasivelyassessbonedensityatthehipandlumbarspine.The
scanfacilitatescalculation ofa T-score(comparison withthebonedensityof a30-yearold,seeBox24.1)andaZ-score(agematched).
Box24.1T-scores
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Score≥–1.0=normalbonedensity
Score–1.1to–2.4=osteopenia
Score≤–2.5=osteoporosis
Source:datafromAssessmentofFractureRiskanditsApplicationtoScreeningforPostmenopausal
Osteoporosis.Geneva1994.WHOTechnicalReportSeries843.
Management
Lifestyleandsimpleinterventions
Encouragepatientsto:
Performregularweight-bearingexercises
Stopsmoking
Reducealcoholconsumption
Eatfoodswithcalciumregularly.
Pharmacologicalmanagement
CalciumandvitaminDsupplementation
If daily intake of calcium (700–1200 mg/day) or exposure to sunlight is inadequate,
prescribecalciumand/orvitaminDsupplementation,e.g.AdcalD3®,onetabletBD.
Bisphosphonates(firstline)
Forexample,oralalendronate10mgODor70mgonceweekly,oralrisedronate5mgOD
or35mgonceweekly.
Bisphosphonatesblock the action ofinorganicpyrophosphateand thisprevents bone
resorption. Side effects include dyspepsia and bowel disturbance (Box 24.2).
Osteonecrosis of the jaw and atypical femoral fractures are rare but important adverse
effectstowarnpatientsabout.
Contraindications:hypocalcaemia(checkpriortocommencingtreatment),severerenal
impairment(GFR≤35mL/min).
If oral treatment is not tolerated, patients may be referred to a specialist for
consideration of an IVbisphosphonateinfusion,e.g.zoledronicacid, orother specialist
options(see‘Specialisttreatments(non-bisphosphonate)’).
Box24.2Patientinstructionswhentakingbisphosphonates
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Sideeffectssuchasdyspepsiaandoesophagitisarecommonwithbisphosphonates,but
theriskisreducedwhenpatientsaretaughtthecorrectwaytotakethetablets.
Takeonanemptystomachandatleast30minutesbeforeeatingordrinking(exceptforwater)
Swallowthetabletwithafullglassofwater(atleast200mL)whilesittingorstanding
Patientsmustnotliedownfor30minutesaftertheyhavethetablet.
Source:datafromNOGG2017:Clinicalguidelineforthepreventionandtreatmentofosteoporosis.
Specialisttreatments(non-bisphosphonate)
Denosumab(monoclonalantibodyagainstRANKLonosteoclasts,inhibitingactivity):
6-monthlySCinjection
BMDfallswithinterruptionoftherapy
Raloxifene(selectiveoestrogenreceptormodulator):
May be considered in postmenopausal women if low risk ofdeep vein thrombosis (DVT)
and/orhighriskofbreastcancer(reducesbreastcancerrisk)
Hormonereplacementtherapy(HRT):
Maybeconsideredinwomenifaged<60years,or<10yearsaftermenopauseiflowriskof
DVTandbreastcancer
Teriparatide(recombinanthumanPTH):
Maybeconsideredifveryhighriskoffractures.Canbeprescribedforupto2years
Romosozumab(sclerostinantagonist):
Maybeconsideredifveryhighriskoffractures.Canbeprescribedforupto1year
Contraindicatedifischaemicheartdisease/cerebrovasculardisease.
Monitoringandfollow-up
Patientswhodonothaveosteoporosisoninitialassessmentshouldbereassessedafter2
years,orsooneriftheirriskfactorschange.
Patientsonbisphosphonatesshouldbereviewedafter5years(3yearsifonzoledronic
acid).Theyshouldhaveareassessmentoftheirfracturerisk.
If theycontinue to be osteoporotic,or stillfall within the treat section of the NOGG
fracture probability table, consider whether to continue treatment for a maximum of
another5years.
If they are no longer osteoporotic and fall below the NOGG intervention threshold,
considerstoppingthebisphosphonatefora‘drugholiday’andreassessafter1.5–3years.
Specialconsiderations
Pregnancy
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Bisphosphonatesarecontraindicatedinpregnancyandwhilebreastfeeding.
Furtherreading
1.TabernacleB,HoneyM,JinksA(eds)(2009).Osteoporosis.In:OxfordHandbookofNursingOlder
People. Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199213283.003.0017
1Consensusdevelopmentconference:diagnosis,prophylaxisandtreatmentofosteoporosis. Am JMed.
1993;94:646–50.
2FRAX®FractureRiskAssessmentTool.Availableat:http://www.sheffield.ac.uk/FRAX
3QFracture®-2016riskcalculator.Availableat:http://qfracture.org
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